Office o/p est low 20 min
CPT code 99213 is used when an established patient returns to their doctor's office for a routine follow-up visit that involves low to moderate complexity medical decision-making and typically takes about 20 minutes.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Use time-based selection when it favors you: if total time on date of encounter is 20-29 minutes but MDM only reaches 99212 level, you can still bill 99213 based on time alone
Impact: Can increase reimbursement by $33.23 (difference between 99212 at $55.72 and 99213 at $88.95) when time threshold is met
Document chronic condition management explicitly: for established patients with 2+ chronic conditions, clearly document monitoring, medication review, and ordering/reviewing data to meet low MDM elements
Impact: Proper chronic disease documentation supports 99213 level and reduces downcoding risk from payer audits by 40-60%
Capture all time elements for time-based billing: include only time spent on date of encounter (face-to-face and non-face-to-face activities like reviewing records, ordering tests, communicating with other providers, and documenting)
Impact: Adding non-face-to-face time documentation can push visits from 99212 (10-19 min) to 99213 (20-29 min) threshold, worth $33.23 per encounter
Bill telehealth visits at non-facility rate: ensure you use place of service 02 (telehealth) or 10 (patient home) with modifier 95 to receive the higher non-facility rate
Impact: Proper telehealth coding yields $88.95 vs. potential facility rate of $63.72, a difference of $25.23 per visit
Verify established patient status: patient must have received professional services from the same physician/group within the past 36 months; otherwise use new patient codes 99202-99205
Impact: Using 99213 for new patient will result in claim denial; new patient equivalent 99203 pays $121.85, so missed revenue opportunity of $32.90
Don't undercode: if MDM reaches moderate level (3+ problems, moderate data review, or moderate risk), bill 99214 instead of automatically defaulting to 99213 for routine visits
Impact: Undercoding from 99214 to 99213 costs $57.07 per visit (99214 pays $146.02 vs. 99213 at $88.95)
Common denials
Insufficient documentation to support level of service - medical necessity or MDM elements not clearly documented to justify 99213 vs. 99212
How to appeal: Submit appeal with highlighted documentation showing at least 2 of 3 MDM elements at low level (limited problems, limited data, or low risk) OR time log showing 20-29 minutes total time. Include payer's E&M guidelines comparison chart.
Services billed as established patient when patient meets new patient criteria (no visit within past 36 months or first visit with new physician in group)
How to appeal: Provide records documenting previous visit within 36 months by same physician/qualified NPP in same group and specialty, or acknowledge error and rebill with correct new patient code 99202-99205.
Bundled denial when billed same day as procedure without modifier 25, or modifier 25 used but E&M not separately identifiable
How to appeal: Resubmit with modifier 25 and documentation clearly separating the E&M service from the procedure (different diagnosis, significant evaluation beyond procedure decision). Show distinct documentation for each service.
Telehealth claim denied due to missing modifier 95/GT or incorrect place of service code
How to appeal: Submit corrected claim with appropriate telehealth modifier (95 for Medicare, GT for specific commercial payers) and place of service 02 or 10. Include dates showing service was during approved telehealth coverage period.
Frequently asked questions
What is the Medicare reimbursement rate for CPT 99213 in 2025?
The 2025 Medicare national average reimbursement for 99213 is $88.95 for non-facility settings (physician offices) and $63.72 for facility settings (hospital outpatient departments). Actual rates vary by geographic location based on Medicare locality adjustments.
How long does a 99213 visit need to be?
A 99213 visit requires 20-29 minutes of total time spent on the date of encounter if using time-based selection. This includes both face-to-face and non-face-to-face time (reviewing records, ordering tests, documentation). Alternatively, you can bill 99213 based on low level medical decision-making regardless of time.
What is the difference between 99213 and 99214?
99213 requires low level medical decision-making (20-29 minutes), while 99214 requires moderate level MDM (30-39 minutes). The key difference is complexity: 99214 involves more problems, more data review, or higher risk. Medicare pays $146.02 for 99214 vs. $88.95 for 99213, a difference of $57.07.
Can you bill 99213 and a procedure on the same day?
Yes, you can bill 99213 with a procedure on the same day if the E&M service is significant and separately identifiable from the procedure. You must append modifier 25 to the 99213 code and document the distinct nature of the E&M service, typically with a different diagnosis or substantial evaluation beyond the procedure decision.
How many RVUs is CPT code 99213 worth?
CPT 99213 has a total RVU value of 2.75 for 2025, consisting of 1.3 work RVUs, 1.35 practice expense RVUs (non-facility), 0.57 PE RVUs (facility), and 0.1 malpractice RVUs. These RVUs multiplied by the conversion factor of 32.3465 determine Medicare payment.
What diagnoses are appropriate for 99213?
99213 is diagnosis-neutral and can be billed with any ICD-10 code that supports medical necessity for an established patient visit with low complexity decision-making. Common scenarios include stable chronic disease follow-up (diabetes, hypertension), acute uncomplicated illnesses (URI, UTI), or routine monitoring visits. The diagnosis must justify the level of service documented.
Is 99213 covered for telehealth?
Yes, 99213 is covered for telehealth by Medicare and most commercial payers, particularly following COVID-19 flexibilities. Bill with modifier 95 (or GT for some payers), use place of service 02 or 10, and ensure the visit meets synchronous audio-video requirements. The reimbursement rate is typically the same as in-person visits at $88.95 for Medicare.